On October 3, 1995, a 13-year-old girl who resided in
Greenwich,
Connecticut, died from rabies virus infection. This was the first
case of
human rabies reported in a Connecticut resident since 1932. This
report
summarizes the investigation of this case, which indicated a bat as
the
probable source of her exposure.

On September 18, the patient reported general fatigue,
stiffness,
tremors, and tingling in her left arm and hand. On September 22,
she
visited a local emergency department because of pain and tingling
in her
left arm and shoulder and a low-grade fever. Cervical radiculopathy
was
presumptively diagnosed and was attributed to her habit of carrying
a heavy
backpack; ibuprofen was prescribed. She was given a cervical collar
and
referred to a pediatric neurologist.

On September 25, because of continuing symptoms, she was
evaluated by
her pediatrician, who noted sensory changes on the left arm and
face. She
was again referred to a pediatric neurologist and, later that day,
was
admitted to a hospital because of complaints of fever, neck pain,
and
painful sensations along her left arm and left side of her face. On
physical examination, her temperature was 100.0 F (37.8 C), and she
was
alert but anxious; there was moderate nuchal rigidity. The only
abnormal
neurologic finding was deviation of the uvula to the left.
Laboratory
findings included a peripheral white blood cell (WBC) count of
13,600/mm3
(normal: 5000-10,000/mm3) with 86% neutrophils, 10% lymphocytes,
and 4%
monocytes. Her cerebrospinal fluid (CSF) contained 2 red blood
cells/mm3
(normal: 0/mm3) and 100 WBCs/mm3 (normal: 0-5/mm3) with 48%
neutrophils,
40% lymphocytes, and 12% monocytes, total protein of 104 mg/dL
(normal:
less than 40 mg/dL), and glucose level of 53 mg/dL; serum glucose
was 102
mg/dL (normal: 70-110 mg/dL).

The diagnosis on admission was possible Lyme
meningoencephalitis with
peripheral nerve involvement; treatment was initiated with
intravenous
ceftriaxone and dexamethasone. During the 24 hours following
admission, she
became intermittently drowsy then agitated, and occasionally was
disoriented. Subsequent manifestations included deviation of her
tongue to
the right, anisocoria, and progressive weakness of the left arm.
She also
was observed to be apprehensive and had difficulty swallowing,
accompanied
by a prominent aversion to oral intake. Severe pharyngeal spasms
were
elicited by offering a drink of water. The diagnosis of rabies was
considered, and the patient was placed in isolation. She became
increasingly agitated; although she experienced tactile
hallucinations
(i.e., complaining of a sensation of insects in her mouth), she
intermittently was lucid and self-reflective and apologized for her
mood
and hallucinations.

On September 26, the girl was transferred to the
intensive-care unit,
where she was intubated because of progressive bulbar dysfunction.
Beginning September 27, she became progressively less responsive,
and
subsequently lapsed into a coma. On October 3, mechanical
ventilation was
withdrawn, and the patient died. No autopsy was performed.

Rabies was diagnosed on October 2 at the New York State Rabies
Laboratory based on corneal impressions collected on October 1,
which were
positive for rabies virus by immunofluorescence, and based on
rising rabies
virus neutralizing antibody titers of 1:32, 1:64, and 1:512 in
serum
samples collected on September 25, 29, and October 2, respectively.
The
diagnosis was confirmed at CDC through extraction of RNA from
saliva and
corneal epithelia, which was reverse transcribed with
rabies-specific
primers and amplified using the polymerase chain reaction (PCR)
assay.
Nucleotide sequencing of the PCR products at CDC characterized the
rabies
virus as a variant associated with the silver-haired bat,
Lasionycterus
noctivagans.

The girl lived in a single-family dwelling in a wooded
residential
area in Greenwich. Although she denied a history of animal bites,
multiple
potential sources of animal contact were present in the home and
surrounding environment; domestic animals with which she was known
to have
had contact were accounted for and were well. Following the
diagnosis of
rabies, the girl's mother and three siblings recalled that on
approximately
August 19, a bat flying inside the house struck at least one
person; during
this time, the girl was asleep in an upstairs bedroom. Inspection
of the
house and surrounding property by the Greenwich Department of
Health on
September 29 did not identify dead animals or evidence of bats.

Because of possible percutaneous or mucous membrane contact
with the
girl's secretions during September 10-October 3, rabies
postexposure
prophylaxis was administered to 83 persons who reported probable
contact
with the patient's saliva: 46 health-care workers, 29 children,
four family
members, three family friends intimately involved in the girl's
care, and
one other adult.

Editorial Note

Editorial Note: Since the 1950s, bats have accounted for an
increasing
proportion of variants of rabies virus transmitted from wildlife
reservoirs
to humans. The rabies virus variant identified in this case, and in
a case
in New York in 1993 (1), is associated with the silver-haired bat,
a
solitary, migratory species with a preferred habitat of old-growth
forest.
However, in neither of these cases was a clear history of bite
exposure to
a bat or any other animal established. Of the 28 cases of human
rabies
diagnosed in the United States since 1980, this case was the 15th
to be
associated with bats; 10 of the virus variants obtained from these
15
persons have been characterized as a silver-haired bat variant.

Bat rabies is enzootic in the United States, and cases have
been
reported from all 48 contiguous states (1). In Connecticut, of the
671 bats
submitted to the state laboratory for testing during 1991-1995, a
total of
47 (7%) were positive for rabies. Nine of the bats diagnosed with
rabies in
Connecticut during 1995 were sent to CDC for viral typing. Eight of
the
bats were infected with a variant associated with the common big
brown bat
(Eptesicus fuscus) and one bat was infected with a rabies virus
variant
associated with red bats (Lasiurus borealis). None of the bats were
identified by species. In New York state, of the 6810 bats
submitted to the
state laboratory for rabies testing during 1988-1992, a total of
312 (4.6%)
were positive for rabies; of these, approximately 90% were from E.
fuscus.
Only 25 of the submitted bats were silver-haired bats, of which
only two
were positive for rabies virus (2).

The findings of the investigation of a recent case in
Washington
suggest that even apparently limited contact with rabid bats may be
associated with rabies transmission (3). Because bites from bats
may be
very small, an exposure may not be recognized -- particularly when
an
unattended child may not be able to accurately relate events to an
adult.

The case described in this report and reports of similar cases
(1,3,4)
underscore the national recommendation that, in situations in which
a bat
is physically present and the person(s) cannot reasonably exclude
the
possibility of a bite exposure, post- exposure prophylaxis should
be given
unless prompt capture and testing of the bat has excluded rabies
virus
infection.

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